Resource and Support Systems for Community Health Workers Increases Demand for Quality Services and Community Participation in Uttarakhand

Background: India’s National Rural Health Mission (2005) introduced accredited social health activists (ASHAs), CHWs receiving performance-based remuneration, as an interface between the community and the public-health system. Uttarakhand, with hilly terrain, scattered settlements and poor road connectivity adversely affected ASHAs’ reach and potential remuneration. Methods: Under USAID Innovations in FP Services Project (2005-2012), FuturesGroup provided technical assistance to the State of Uttarakhand to design a pilot to improve selection, training, mentoring, and systems for ASHAs.  Under “ASHA Plus,” ASHAs covered flexible populations, were reimbursed for a wider range of services, trained in micro-planning tools and management information systems (MIS), had job-aids and tools for record keeping. State ASHA Resource Centre, State ASHA Mentoring Group, and District ASHA Resource Centres were establsihed. Results: Comparison of baseline(2006) and 2007-08 MIS data indicated improved services: 3 ANC visits (30% to 59%); preganncy registration (35% to 49%); institutional births (27% to 58%). Community-level outcomes: better outreach to underserved areas, awareness and demand of health schemes, and community monitoring; at the systems level, increased linkages service delivery points, record keeping, and interaction with other health cadres. In 2009, the government scaled up coverage in six districts (0.26 to 3.13 million people). In 2010, it expanded the supervisory system, the remuneration package, and established ASHA resource system statewide. Conclusions: Minor policy and systemic changes to suit local context, and strengthening capacities of CHWs can improve service uptake, accelerate improved health outcomes, and increase social participation and monitoring, with equitable service delivery leading to empowered communities.